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Waste Tire Sul 4y & Inspection Report nspection Report Number ■ <br /> CIWMB81'fornia <br /> (New 04104) Survey Form - Paae 1 Il - 1127663 <br /> California Integrated Waste Management Board ♦ g <br /> Part_A_- Survey__ -_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - Q 1 Inspection Type (Fill one) <br /> Site Suffix: b l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local � /O, „n If Referral,choose referral type(Fill one) <br /> Identifier: JCI 1( �, l_ v1 l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physicat Address LI�i pW <br /> �}�� Inspection Date I C) <br /> �v v �� Time In Time Out <br /> `/ <br /> Business Rep Title t� O AM7 O AM <br /> a PM ` ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger ® Generator ®Outdoor <br /> 0 Q Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive i Q Truck <br /> Longitude - Q Planned j Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> /,iness-Rep's <br /> ----Signature one Number I s e t rs S at a Phone Number <br /> INSTRUCTIONS ON BACK f Correct:* incorrect , V = 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cow ® ■ <br />